✅F2 (GI / RHEUM-ORTHO / HEME-ONC/ENDOCRINE/ SURGERY) Flashcards
1
Q
Name the differentiating sx between [Mallory Weiss tear] and [Boerhaave Esophageal Perforation]
A
both have NV➜ hematemesis
MW: [partial thickness esophageal tear]
________________
BEP: [FULL thickness esophageal tear] | [Perforation sx (fever/retrosternal cp/ L pleural effusion)]
2
Q
[Boerhaave Esophageal Perforation] dx
A
[water soluble contrast esophagogram]
3
Q
[Boerhaave Esophageal Perforation] MOD
________________
Delay of surgical intervention leads to what complication
A
repeat vomiting ➜ [distal 1/3 full thickness esophageal tear] ➜ release of gastric content into sterile mediastinum
= [ACUTE RETROSTERNAL CHEST PAIN (+/- L pleural effusion c/b PTX or Pneumomediastinum)]
________________
Fatal Mediastinitis within 24H
4
Q
cp for [Perforated gastric ulcer]
A
acute severe abd pain with [free air under diaphragm on upright CXR] + HDUS= SURGICAL EMERGENCY
________________
HDUS: HemoDynamicallyUnStable
5
Q
Scoliosis is mostly caused by ⬜
What clinical features are c/f pathologic Scoliosis (i.e. spinal tumor)? -4
A
idiopathic
________________
Back Pain / Neuro ∆ / [rapid progressive curve] / [abnormal vertebrae]
6
Q
Between Marfan and Ehlers Danlos, which is a/w velvety skin & easy bruising?
A
Ehlers Danlos
7
Q
What similar s/s do Marfan and Ehlers Danlos have in common? -4
A
[MSK (joint hypermobile / Pectus excavatum / Scoliosis)]
[Cardiac: MVP]
8
Q
Why are pts with Ehlers Danlos Syndrome at ⇪ risk for acute mitral regurgitation?
A
EDS = in addition to [Skin/Msk/GU] sx…
EDS also cuases myxomatous degeneration (and ultimately RUPTURE) of the chordae tendineae
9
Q
[High Risk SQC (on face/ears/sensitive areas)] is treated using ⬜. Why is this tx used?
________________
low risk SQC = < 2 cm lesions on trunk or extremities (excluding hands/feet)
A
[HRS] = [Mohs micrographic surgery] ; has higher cure rate than standard exicision and is great for cosmetic or functional areas
________________
[LRS] = curettage + electrodesiccation (mechanically + electrically destroys CA)
10
Q
⬜ infections develop in up to 50% of patients with acute variceal bleeding.
Management -2?
A
BACTERIAL (SBP/PNA/UTI) ;
( [Ceftriaxone IV x 7 days] prophylaxis)
11
Q
Why do patients with [(SSS) Scleroderma Systemic Sclerosis] receive routine Pulmonary Function Test when diagnosed ?
A
Both SSS types {Diffuse (ILD)} and {CREST Limited (pulmonary HTN)} ➜ [⇪ Lung pathology] = PFT (to guide/track disease)
12
Q
In [Scleroderma Systemic Sclerosis], list the 2 long term complications for SSS type:
[Diffuse Cutaneous (Anti Scl-70)]
________________
[CREST Limited Cutaneous (AntiCentromere)]
A
[Diffuse Cutaneous (Anti Scl-70)] = Interstitial Lung Dz + Renal Crisis ________________
[CREST Limited Cutaneous (AntiCentromere)] = pulmonary htn + Renal Crisis
13
Q
the primary tx for all Hernia is what?
A
surgery
_________________
complications: incarceration vs strangulation
14
Q
characteristic features of [Toxic Adenoma Thyroid Nodule]
A
SYMPTOMATIC HyperThyroid
+
[Radioiodine uptake in nodule] with suppressed uptake in remainder of gland]
15
Q
tx for [Toxic Adenoma Thyroid Nodule] -2
A
[PreTx (Methimazole)]
➜
[DefinitiveTX (RADIOACTIVE IODINE ABLATION OR SURGERY)]
16
Q
Polycythemia is ⬜ in Men and ⬜ in Women. measuring EPO is first step in working up Polycythemia
_________________
⬜ is the most common cause of 2° polycythemia.
A
hgb: M >18.5 | W>16.5
_________________
CHRONIC HYPOXIA
(consider carboxyhgb and sleep apnea)
_________________
polycythemia? ➜ [**low EPO = polycythemia vera] vs [HIGH EPO = 2° polycythemia (chronic hypoxia or Renal Cell Carcinoma)]
17
Q
Polycythemia is ⬜ in Men and ⬜ in Women. What’s the first step to evaluating polycythemia?
_________________
How do you interpret this data? -2
A
hgb: M >18.5 | W>16.5
measure Erythropoietin
_________________
polycythemia? ➜ [**low EPO = polycythemia vera] vs [HIGH EPO = 2° polycythemia (chronic hypoxia or Renal Cell Carcinoma)]
18
Q
s/s of Compartment Syndrome -6
A
[Pain (especially with Passive stretch)]
Paresthesia
Poikliothermia
_________________
Paralysis
Pulselessness
Pallor
19
Q
Name and Describe the test used to diagnose [Achilles tendon complete rupture]
A
Thompson test
while patient is prone, MD squeeze’s patient’s calf ➜
[NO plantar flexion = RUPTURE] vs [+plantar flexion = Achilles intact]
20
Q
Tx for Fibromyalgia -4
A
1st: Aerobic Exercise
2nd: TCAs / SNRIs / Anticonvulsants
21
Q
FibroMyalgia is a clinical diagnosis
What labs are ordered to rule out other similar conditions? -3
A
TSH / CBC / ESR
________________
FibroMyalgia
22
Q
What are the 4 most common causes of Myopathy (⬆︎ CPK)
A
Statins Probably hurt Muscles
- Statins
- Polymyositis vs. Dermatomyositis (autoimmune)
- Muscular Dystrophy
- hypOthyroidism (OR HYPERthyroidism)
23
Q
What’s the single most important risk factor for Osteoporosis?
A
AGE
_________________
less RF: fam hx / smoking / EtOH
24
Q
What are the 2 features of [Subclinical hypOthyroidism]?
________________
[Subclinical hypOthyroidism] is usually not treated. What are the 4 exceptions?
A
[⇪ TSH] with [normal T4 Thyroxine]
________________
- antiThyroid antibodies (antiTPO)
- abnormal lipid profile
- hypOthyroidism sx
- ovulatory/menstrual dysfunction
25
Angiodysplasia is an uncommon cause of ⬜
What are the 3 major risk factors?
[painless GI hemorrhage]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Aortic Stenosis / Von Willebrand disease / Chronic Kidney Disease
26
# define
Specificity
sPecificity = [true negative]
## Footnote
*= "a test's probability (in the ABSENCE of disease) a patient test negative"*
27
Chronic Granulomatous Disease is a (⬜*Mode of Inheritance*) that usually p/w ⬜ shortly after birth from ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MOD for Chronic Granulomatous Disease
[X-linked **recessive** 1° immunodeficiency] ; recurrent infections ;
[catalase positive organisms (**Aspergillus** = MAJOR COD / **Staph A**=liver/skin abscess/adenitis)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Loss of NADPH oxidase] impairs intracell killing of [phagocytosed bacteria and fungi] ➜ recurrent infections
28
Central Retinal Artery Occlusion
management? -2
[⬇︎Intraocular pressure] + Optho consult
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
acute pain**LESS** monocular vision loss
29
Central Retinal Artery Occlusion
clinical presentation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Fundoscopy findings? -2
acute pain**LESS** monocular vision loss
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Retinal pallor 2/2 diffuse ischemia] + [Cherry Red Macula]
30
Macular degeneration affects [⬜ central | peripheral] vision, while Glaucoma affects [⬜ central | peripheral] vision
Ma**C**ular --\> **C**ENTRAL vision loss
## Footnote
*with straight lines appearing curvy (wet/exudative-neovascular= aggressive and uL while dry/atrophic=gradual and BL)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Glaucoma --\> peripheral vision loss (gradual tunnel vision)
31
clinical presentation for
Retinal Detachment - 3
1. Floaters
2. [Descending Visual Curtain **PERIPHERAL➜ central**]
3. Photopsia Flashes of Light
32
clinical definition of Rectal Prolapse
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When is surgery indicated? -2
when mucosal or full-thickness layer of rectal tissue slides thru anus
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[complete rectal prolapse] or
[prolapse with fectal incontienence and/or constipation]
33
what's management of
```
partial SBO (*air in distal colon on XR*)? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
```
COMPLETE SBO?
partial SBO = [conservative x 24h] --(sx persist)--\> [XLAP]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
COMPLETE SBO = XLAP
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*conservative = IVF / NG suction / electrolyte correction*
34
⬜ should always be considered in patients with multiple complicated fractures.
What is the symptom triad for this condition?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this prevented?
Fat Embolism ;
**PBS**
**P**etechial rash
**B**rain impairment
[**S**OB (respiratory insufficiency)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Early immobilization and operative fixation of fracture
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*HEPARIN/ENOXAPARIN DOES NOT AFFECT FAT EMBOLISMS*
35
Typically, [CRC Colonoscopy screening] starts at age ⬜ --and if normal--\> repeats every ⬜ years
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does this differ for patients who have Ulcerative Colitis -2
45 ; 10
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
36
Typically, [CRC Colonoscopy screening] starts at age ⬜ ---and if normal--\> repeats every ⬜ years
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you manage a patient who instead underwent flexible sigmoidoscopy and was positive for adenomatous polyps?
45 ; 10
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**COLONOSCOPY STAT**
(**follow +sigmoidoscopy with STAT Colonoscopy** to scan entire colon for proximal colon adenomas and advanced neoplasia)
37
Typically, [CRC Colonoscopy screening] starts at age ⬜ --and if normal--\> repeats every ⬜ years
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does this differ for patients who have either [high risk adenomatous polyps] or [First Degree Relatives with CRC] ?
45 ; 10
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*HR: 40 ; 5*
*IF HIGH RISK: [*Cscope at 40 yo (or 10y prior to age FDR received dx) (which ever is first)]
then [Repeat every 5 years (or 10 if FDR diagnosed \> 60 yo)]
38
Dumping Syndrome MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dumping Syndrome Sx(5)
rapid emptying of **hyper**tonic stomach contents into Duodenum & small intestine (usually after gastrectomy or RYGB) --\> **DDUMP**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**D**iarrhea
**D**iaphoresis
[**U**mbilical ABD Pain]
**M** (N)ausea
**P**alpitations
*worst after eating and better at night*
39
[SIBO - Small Intestinal Bacterial Overgrowth] MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical features of SIBO (6)
surgery ➜ blind loop of small intestine that (especially if partially obstructed by intraabd adhesion) allows bacterial overgrowth ➜ SIBO sx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**S**tinky flatulence / [**I**ntestinal lack of TTP OR Fever] / [**B**loating | B12 deficiency | +Breath LactuLOSE test] / [**O**asis WATERY Diarrhea]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**NO** abd pain (*CDiff has diffuse abd pain*)]
[**NO** fever (*CDiff has FEVER*)]
40
Clostridioides difficile MOD
Ingested spores (transmitted by fecal-oral route) germinate in COLON = become fully functional bacilli ➜ proliferate unchecked **when COLON FLORA IS DISRUPTED** ➜ [⇪ release of exoToxin A and B] ➜ mucosal inflammation ➜
[PROFUSE WATERY DIARRHEA ≥ 3 LOOSE STOOLS daily]
41
[West Nile Arbovirus] can cause ⬜ following a bite from an infected ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What time of year does this typically present?
MeningoEncephalitis ; mosquito
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Summer
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Fever / AMS / HA / Nuchal rigidity / Vomiting*
42
clinical presentation for [Open Globe Laceration] -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
what causes this injury?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management? -4
teardrop pupil and [DEC visual acuity]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[small sharp objects penetrating globe at high velocity]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[IV abx / eye shielding / eye CT / Optho consult]
43
Elevated ⬜ in pts with [Medullary Thyroid CA s/p total thyroidectomy] indicate ⬜ ?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you work this up? -3
calcitonin; **METASTASIS**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*metastatic* medullary thyroid CA dx] ➜ [CT neck/chest (look for metastasis)] ➜ Surgical Resection
44
What type of goiters develop from iodine deficiency?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you treat [retrosternal goiter w/compressive sx]?
multiNodular
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Surgery
45
Diagnostic criteria for Nightmare Disorder - 3
1. Recurrently wakes from sleep re**M**ember the nightmare
2. Child is fully alert on awakening
3. Child can be consoled
## Footnote
*Night**M**ares occur during RE**M** and is developmentally normal for kids*
46
What is the difference between Sleep Terrors and Nightmare Disorder? - 4
Sleep terrors are :
1. NON-REM disorder
2. with incomplete awakenings
3. and can NOT be consoled
4. and pt **S**eems to forget the dream
47
For cp, what are 2 ways to differentiate Sleep Terrors from [RSRBD]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*RSRBD = REM Sleep Related Behavioral Disorder*
[Sleep Terror = NONrem] | [**R**SRBD= **R**EM]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[ST = abrupt hyperarousal from sleep] | [RSRBD="acting out dreams"]
48
What is the clinical progression for [NONrem sleep disorders] like Sleep Walking and Sleep Terrors?
onset 4-12 yo ➜ **RESOLVES SPONTANEOUSLY ≤ 2 YEARS FROM ONSET** --(if SEVERE = low-dose benzo qhs)
49
Describe the clinical tool used to assess whether a pt is seriously contemplating suicide
**SAD PERSONS**
## Footnote
*Each is worth 1 point and* *[normal 4--(outpt tx)--**7** --\> Hospitalize now!]*
**S**ex Male
**A**ge external to 19-45
**D**epression diagnosis
**P**revious attempt hx (STRONG RISK FACTOR!)
**E**tOH/substance abuse
**R**ational thinking impaired (psychosis, delusions, hallucinations)
**S**ocial support lacking
**O**rganized plan
**N**o significant Other
**S**ickness physically (i.e. chronic pain)
50
What is Statistical power?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you mitigate low statistical power?
ability to detect an association if that association exist. Based on sample size. Larger sample size helps control all confounders ➜ ⇪ Statistical power
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**META ANALYSIS** (pools data from several studies to INC statistical power)
51
Subclinical Hyperthyroidism Thyrotoxicosis is defined as ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When is treatment indicated for subclinical Hyperthyroidism -3
low TSH with normal T4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
treat with rx or Radioctive iodine if
[TSH \< 0.1] or [≥65 yo] or [comorbid conditions present (heart disease, osteoporosis)]
52
[Clubfoot Equinovarus] is a deformity of the ⬜ bone which results in what clinical presentation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx for this?
Talus; *PIA* BL feet [**P**lantar flexed + **I**nverted + **A**DDudcted]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
serial Foot Cast
53
*infant presents with refractory candidiasis*
suspected diagnosis?
infant HIV
54
s/s Zinc Deficiency -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*must be confirmed by lab*
Doesn't grow
Diaper rash
Dermatitis perioral
Diarrhea
55
what are the rules regarding Physicians observing misconduct from another Physician ? -2
Physicians are ethically obligated to report colleagues (to State Medical Boards) who are
impaired/incompetent/unethical
or who subject patients to potentially harmeful tx
56
How do you manage a patient presenting after accidentally swallowing a sharp fish bone?
EMERGENT FLEX ENDOSCOPY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*any sharp object in esophagus must be removed emergently with flex endoscopy*
57
Boundary Violations are defined as ⬜
How are they managed? -3
serious transgressions against physician safety and/or well-being (such as unwanted touching)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1st: reinforce hospital code of conduct with patient
2nd: **REASSIGN PHYSICIAN**
3rd: document alert in patient's chart
58
*patients with large TBSA burns have high mortality rates*
How do you determine if burn patients require hospice?
rBS = [age + TBSA (+17 if inhlation injury present)] **\> 140**
## Footnote
*[revised Baux score] \> 140 = poor survival pgn*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
59
How do you differentiate cp of duodenal ulcer vs gastric ulcer
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Whats the tx for HPylori Ulcer -3
[**D**EC = **D**uodenal] \<--(EPIGASTRIC PAIN AFTER MEAL)--\> [**G**ETS WORST = **G**astric]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**CAP** it!
**C**laroithromycin / **A**moxicillin / [**P**PI omeprazole]
60
After Triple Therapy, what 3 clinical elements warrants **CONFIRMATION** of H Pylori eradication?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is eradication confirmation done? -2
duodenal ulcer | ongoing dyspepsia | MALT lymphoma
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
([Urea Breath test] or [Fecal Antigen test])
x 4 weeks after Triple Therapy
61
clinical presentation for Meniscal tear
subacute or chronic **LOCKING/CATCHING** sensation of the Knee
## Footnote
+/- ➜ gradual effusion
62
In patients with SEVERE malnutrition, which route of administration is the preferred method of rehydration? why?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**ORAL** --(if oral insufficient)--\> NG --(if pt in shock)--\> [IV 10 cc/kg over 30m]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
IV rehydration in chronic malnourishment may cause fluid overload ➜ HF
63
What is Chronic Exertional Compartment Syndrome?
muscular volume expansion during endurance exercise ➜ INC pressure within fascial compartment **of BL lower leg**➜ chronically impairs tissue perfusion .
alleviated with rest and nml activity
*TX = elective fasciotomy*
64
What are the 4 possible effects amiodarone can have on the Thyroid?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How are each treated?
65
how are hip fractures in the elderly managed? (2)
[ambulatory/stable] = **ORTHO SURGERY WITHIN 48H**
[non-ambulatory/dementia/medically unstable] = Nonoperative management
66
Organophosphate poisoning MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx? (2)
ACh**E** inhibitor --\> TOO MUCH ACh in cleft --\> DUMBELS
## Footnote
* Organophospahtes are used in Agricultural Pesticides*
* TX = Atropine + [Pralidoxime (reactivates ACh**E**)]*
67
Biostatically, what are the major benefits of smoking cessation?
Smoking Cessation **AT ANY AGE** ⬇︎ risk of [all-cause mortality and CV events] within 5 years after you stop
68
How should you counsel on smoking cessation? (5)
5 A's (KCVSR)
* A*s**K** patient about their tobacco usage every visit
* A*s**C**ertain readiness to quit
* A*d**V**ise to quit
* A***S**sist with Rx or cessation programs
* A***R**range quit date + follow up appointments
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*smoking cessation ⬇︎ [all cause mortality (including Lung CA, CV events and COPD)] within 5 years after you stop*
69
sx of Viral Meningoencephalitis (5)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Etiologies include (⬜3) and treatment is (⬜2)
*[MeningoEncephalitis (+AMS* and *focal neuro* ∆ *)] vs [Meningitis (No AMS)]*
70
What are the sx of Acute Epididymitis (4)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the causes? (2)
1. ***E**pididymitis = **E**levation of testicle alleviates*
2. Edema of Epididymis
3. uL POST testicle pain
4. [(if E.Coli BOO) DUS urianry sx]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[STI (Chlamyd/Gonorrhea)] \< [Age 35] \< [Bladder outlet obstruction (E.Coli)]
71
What's the 1ST medication given for Atheroslcerosis?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When is it actually indicated to give? (3)
STATIN
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* [LDL ≥190]
* [age ≥40 + DM]
* [(10y ASCVD risk) ≥7.5%]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*THIS IS REGARDLESS OF BASELINE LDL*
72
* [SEVERE HYPERTRIGLYCERIDEMIA] occurs when serum level TAG is ⬜ mg/dL. SEVERE HYPERTRICLYCERIDEMIA is a risk factor for developing ⬜*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
Name tx for SEVERE HYPERTRICLYCERIDEMIA -2
\>1000 ; [HTAP - HyperTriglyceridemia Associated **PANCREATITIS**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Insulin or Apheresis (to lower serum TAG acutely)] + [FIBRATES (for HTAP tx and px)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Pts with HTAP hx require long term Fibrates for acute tx and prevention*
73
Clinical presentation for Illness Anxiety disorder
Anxiety over possibility of having serious Illness even though there are **little to no symptoms**
for ≥6 months
*In Somatic symptom disorder....Somatic symptoms ARE present!*
74
# define Spondylolisthesis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical presentation
ANT slippage of 1 vertebral body over another 2/2 BL **defects of the [pars interarticularis (spondylolysis)]**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Teen athlete who performs repetitive back extension and rotation ➜ low back pain exacerbated by lumbar extension
## Footnote
*tx = analgesics / activity cessation x 90d*
75
describe Autoimmune hepatitis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
lab findings (2)
```
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
diagnostic labs (2)
```
autoimmune progressive parenchymal liver damage of young women that may ➜ cirrhosis and liver failure in 6 mo
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[⇪ALT and ⇪AST +/- ALP] and [normal bilirubin level]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[ANA] / [AntiSmooth Ab]
76
[Thiamine B1] deficiency causes ⬜ and **BeriBeri**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Describe BeriBeri (2)
[Wernicke Korsakoff Syndrome] and [BeriBeri]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**BeriBeri** (Wet vs. Dry vs. BOTH) is associated with...
1. Heart involvement = ***WET***
2. Symmetrical Peripheral Neuropathy = ***DRY***
*[Thiamine B1] is needed to Decarboxylate a-ketoacids (carb metabolism)*
77
Chronic Granulomatous Disease MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management? (2)
[X-linked defect in neutrophil (NADPH oxidase)] ➜ impairs neutrophil superoxide formation ➜ impaired neutrophil intracellular killing ➜ recurrent [catalase positive infections]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[bactrim+ itraconazole] px
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* (catalase+) infections = staphA/Burkholderia cepacia/Serratia/Nocardia/Aspergillus*
* dx = nitroblue tetrazolium test*
78
How are the results of the D-xylose test interpreted? ; How does Rifaximin play a role in this?
**In patients with steatorrhea**/**fatty stool**...
It differentiates between
1. **Celiac disease** (D-xylose will be LOW in the urine because it can't be reasbsorbed in the small intestine because of villous atrophy)
2. **Pancreatic insufficiency** (D-xylose will be HIGH because absorption occurs normally and pancreatic enzymes never break down D-xylose)
\*\*Small Intestine Bacterial Overgrowth can digest D-xylose before it has the chance to be reabsorbed --\> Falsely low D-xylose. Rifaxmin abx prevents this\*\*
79
What type of diarrhea is associated with decreased stool osmotic gap \< 50
Secretory
## Footnote
*these are larger volume diarrhea that occurs during fasting or sleep*
80
What type of diarrhea is associated with INCREASED stool osmotic gap \> 125
Osmotic
## Footnote
*ex: Lactose intolerance*
81
What are the laboratory findings for Lactose intolerance? - 5
## Footnote
*Lactose intolerance is most commonly seen in Asians*
1. ⬆︎stool osmotic gap (osmotic diarrhea)
2. +reducing substances in stool
3. **+hydrogen breath test (indicates intestinal bacterial carbohydrate catabolism)**
4. acidic stool pH
5. NO steatorrhea
## Footnote
*Lactose Intolerance is most commonly seen in Asians*
82
What are the laboratory findings for Lactose intolerance? - 5
## Footnote
*Lactose intolerance is most commonly seen in Asians*
1. ⬆︎stool osmotic gap (osmotic diarrhea)
2. +reducing substances in stool
3. **+hydrogen breath test (indicates intestinal bacterial carbohydrate catabolism)**
4. acidic stool pH
5. NO steatorrhea
## Footnote
*Lactose Intolerance is most commonly seen in Asians*
83
What type of diarrhea is associated with INCREASED stool osmotic gap \> 125
Osmotic
## Footnote
*ex: Lactose intolerance*
84
What type of diarrhea is associated with decreased stool osmotic gap \< 50
Secretory
## Footnote
*these are larger volume diarrhea that occurs during fasting or sleep*
85
There are 4 Malabsorption syndromes
Describe clinical features of Chronic Pancreatitis (2)
86
There are 4 Malabsorption syndromes
Describe clinical features of Lactose Intolerance (4)
87
Classic triad for [Spindal Epidural Abscess]
1-focal back pain
2-neuro deficits
3-fever
*dx = contrast MRI*
88
Spinal Epidural Abscess p/w ⬜ ⬜ and ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you manage SEA? (4)
focal back pain / neuro deficits / fever
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
1. [contrast MRI spine]
2. [Infxn labs (ESR/CRP/CBC/bcx/spinal aspirate cx)]
3. [IV Vanc + Ceftriaxone]
4. [Emergency Surgical Decompression/I&D within 24 HOURS]
89
What are the 5 steps to appropriately transport an amputated extremity?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How long will this sustain viability?
"**SPLIT** extremity!? wrap in... "
**S**aline moistened gauze. THEN put in-
**P**lastic bag.
**L**id seal bag shut before putting it on
**I**ce/Saline 50/50 mix bed. to keep
**T**emperature ideal (33.8 - 50 F) as to NOT FREEZE extremity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
24 hours
90
tx for Viral gastroenteritis (3)
*self-limited*
## Footnote
1. oral rehydration (mild)
2. IV REHYDRATION (SEVERE)
3. **Low Fat/Low Sugar** regular diet as tolerated
91
what are the s/s of Viral gastroenteritis (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
it is transmitted via ⬜ with which 2 viruses?
[**WATERY DIARRHEA** +/- vomiting]
Abd pain
[+/- Fever]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
92
Explain what the HIV test *window period* is and why it's important
during first 4 weeks of infection, low titers of antigen and antibody may ➜ **FALSE NEGATIVE**. So if suspicious for HIV infection, retest ≥4 weeks after initial exposure
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*HIV test = p24 antigen + HIV1 ab + HIV2 Ab*
93
Prior to initiating HAART for HIV infection, coinfection with ⬜ is determined first. Why is this?
Hepatitis **B**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Some antiretrovirals have DUAL activity against HIV and H**B**V
94
The major side effects of [INH Isoniazid] for TB are peripheral neuropathy and ⬜.
How do you manage each side effect?
[HEPATITIS]
## Footnote
**(*****measure LFTs** now then q 3 mo ➜ dc INH if LFT [≥5x baseline] or [≥3x baseline with sx] )*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
***supplement** INH **with [PYRIDOXINE B6]** (INH outcompetes ([pyridoxine B6] - a cofactor in synthesizing synaptic NTS) so giving more [pyridoxine B6]) ➜ prevents*
[peripheral neuropathy]
95
Describe the process of EtOH breakdown to Acetic Acid and explain how Metronidazole disrupts this
Metronidazole has Disulfiram-like activity --\> Acetaaldehyde accumulation --\> Flushing/NV/Cramps after drinking
96
MOD for APAP overdose
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does EtOH affect this process? (2)
*DELAYED HOSPITAL PRESENTATION = WORST OUTCOME*
during APAP OD,
APAP --(*via CYP**2E1***)--\> [toxic NAPQI] and [toxic NAPQI] depletes intrahepatic glutathione as it's ➜ [NON-TOXIC cysteine & mercapturic acid]
once intrahepatic glutathione is all depleted [toxic NAPQI] accumulates ➜ hepatotoxicity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*acute EtOH competes for 2E1 ➜ DEC [toxic NAPQI] = protective*
*CHRON**IC** EtOH upregulates 2E1 ➜ **IC** [toxic NAPQI] = exacerbant*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Activated Charcoal (if within 4h post ingestion)]- *binds APAP*
[NAC (most effective within 8 hrs post ingestion)] ⇪ intrahepatic glutathione and restores [(toxic NAPQI) ➜ (nontoxic cysteine & mercapturic acid)]
97
MOD for APAP overdose
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
⬜ and [N-acetylcysteine] are mainstay treatments, but NAC is most effective if given ⬜. How does NAC work?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*DELAYED HOSPITAL PRESENTATION = WORST OUTCOME*
during APAP OD,
APAP --(*via CYP**2E1***)--\> [toxic NAPQI] and [toxic NAPQI] depletes intrahepatic glutathione as it's ➜ [NON-TOXIC cysteine & mercapturic acid]
once intrahepatic glutathione is all depleted [toxic NAPQI] accumulates ➜ hepatotoxicity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Activated Charcoal (if within 4h post ingestion)]- *binds APAP*
[NAC (most effective within 8 hrs post ingestion)] ⇪ intrahepatic glutathione and restores [(toxic NAPQI) ➜ (nontoxic cysteine & mercapturic acid)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*protective \< [EtOH chronicity] \< exacerbant*
98
How do you diagnose APAP OD? (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
⬜ and [N-AcetylCysteine] are the 2 mainstays of treatment. When is NAC most effective?
*DELAYED HOSPITAL PRESENTATION = WORST OUTCOME*
[Activated Charcoal (if within 4 h post ingestion)]
## Footnote
*NAC is most effective when given **within 8 hours post ingestion** prior to hepatoxicity*
99
Describe pathophysiology for acute APAP OD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Describe the 4 clinical stages of APAP OD
100
*[EBV infectious mononucleosis] ⇪ risk of splenic rupture, intraabd hemorrhage and hypOvolemic shock*
What is the 1st step in managing splenic rupture 2/2 EBV?
VOLUME RESUSCITATION
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*once stable (SBP\>90) obtain CT abd to assess severity] or [XLAP if pt remains HDUS despite volume resuscitation]*
101
*Slipped Capital Femoral Epiphysis is a complication of childhood obesity*
MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management?
fat teen ➜ [ANT SUP slippage of femoral neck] ➜ [POST INFERIOR displacement of Femoral head] ➜ [Months of vague hip/knee pain]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[surgical pinning **within 24 HOURS**]
102
*Slipped Capital Femoral Epiphysis is a complication of childhood obesity*
When does this present?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does this present?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx?
puberty (most common hip disorder in fat teens!)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[M: **Months of vague hip/knee pain**] without acute onsets
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
pelvis XRay
*fat teen ➜ [ANT SUP slippage of femoral neck] ➜ [POST INFERIOR displacement of Femoral head] ➜ [Months of vague hip/knee pain]*
103
How does Alcoholic ketoacidosis clinically present? (4)
how is this different from DKA?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx for Alcoholic ketoacidosis?
*suspected Alcoholic with:*
AG acidosis
INC osmolar gap
ketones
variable blood glucose (DKA has BG \> 250)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx = [Dextrose IVF with thiamine]
*dextrose will ➜ insulin secretion ➜ metabolism of ketone bodies to HCO3*
104
In Spinal Stenosis, pts pain is usually exacerbated with \_\_\_\_\_(flexion/extension) and \_\_\_\_\_. It is accompanied with ___ symptoms
spinal st**EEE**nosis
**E**XTENSION ; **E**xertion (vascular claudication) ; neurological
105
You see an elderly patient leaning over to relieve their pain
⬜ is suspected. How is it confirmed?
management? (2)
[Spinal St**E**nosis secondary to Osteoarthritis joint degeneration] ; MRI spine
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx =[lumbar epidrual block] --(if persist)--\> [Laminectomy surgical decompression]
*Shopping cart sign (l**E**aning over for relief) = Spinal st**E**nosis = exacerbated with **E**xtension and **E**xertion*
106
In Lumbar disc herniation, pts pain is usually exacerbated with \_\_\_\_\_(flexion/extension) and accompanied with ___ symptoms
**flexion** ; UNILATERAL radiculopathy and neurological sx
107
*iron deficiency anemia and thalassemia both cause microcytic anemia*
What's a labatory method for differentiating them?
*Mentzer Index = MCV/RBC*
thalassemia \< [Mentzer Index of 13] \< IRON DEFICIENCY ANEMIA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
108
What is the Tuning Fork test ?
easy, inexpensive screen that assess for loss of 2TVP (usually of the BL feet) in DM
*2TVP = 2-point/Touch/Vibration/Proprioreception*
109
How do you treat diabetic neuropathy? (4)
[AGGRESSIVE GLYCEMIC CONTROL]
+
[Neuronal transmission adjusters (Duloxetine|Gabapentin-Pregablin|TCA)]
110
Porcelain Gallbladder is often asymptomatic and found incidentally. What is it?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Why is it clinically significant?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the management?
gallbladder wall calcification (*punctate vs curvilinear*) 2/2 chronic cholelithiasis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INC risk for GALLBLADDER CANCER if *punctate* *calcification* ;
[Prophylacic Cholecystectomy (if +sx or +*punctate calcification*)
111
[AOOD (avascular osteonecrosis osteochondritis dissecans)] etx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx
osteonecrosis (from [CTS \> 20mg/day]/HIV/renal disease) of the [small foot/hand bones], proximal tibia, femoral head, vertebrae, humeral head ➜ bone collapse ➜ joint replacement
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MRI
*stage 4 AOOD ➜ Total Hip Replacement*
112
*Pt jumps from a ladder, landed and now has acute R knee pain*
what injury is he likely to have? why?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Describe the XR
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management?
R patellar tendon rupture ; sudden forceful unopposed quadricep contraction (landing after jumping) ➜ patella tendon rupture = ANT knee pain/effusion , **[inability to extend knee]** or [**maintain a straight leg with flexed hip**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
high-riding patella
* requires surgery in \< 10d*
* patellar stress fx conversely is gradual osnet, not sudden*
113
What is Osgood Schlatter Disease
**Traction apophysitis of the tibial tubercle** from Self-limited irritation of the growth plate at the tibial tuberosity (front of tibia) possibly --\> hard nodule, relieved with rest/growth spurt
## Footnote
*xray: lifting of tubercle from the shaft*
114
Osgood Schlatter Disease tx -3
1. NSAIDs
2. Ice
3. self-limited (stops with end of growth spurt)
## Footnote
*xray: lifting of the tibial tubercle from the shaft*
115
Name the 5 major Treatments for Rhematoid Arthritis
***M****ost **L**osers **H**ide **S**ecrets **T**erribly*
**M**TX
**L**eflunomide
**H**ydroxychloroquine
**S**ulfasalazine
[**T**NF inhibitors]
116
When are [TNF inhibitors] used in RA therapy?
What's the major caution with these drugs, and how is this managed? (2)
RA patients who fail first-line therapy
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[a/w opportunistic infections (i.e. reactivates latent TB)]
so... screen with [TB PPD] or [interferon gamma release assay] prior to [TNF inhibitors]
117
*child presents with 2º enuresis*
DDx? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*2º enuresis = bed wetting ≥5 yo after established period of nighttime dryess*
DM (*order CBC/CMP*)
vs
psychological stressor (*I.e. parents' divorce*)
118
cp for McCune Albright syndrome-3
*all [McCune Albright] does is **P P P***
1. **P**recocious puberty
2. **P**igmented cafe au lait spots
3. **P**olyostotic fibrous dysplasia --\> bone defects
119
What is [Idiopathic premature pubarche]?
[precocious (male \<9 / female\<8)] and isolated development of pubic hair
***with NO other endocrine*** ∆
120
Pylephlebitis is described as ⬜, and a rare yet devastating complication of ⬜
[infective suppurative portal vein thrombosis] ; intraabdominal infections
121
cp for Niacin B3 deficiency - 4
**DDDD** Pellagra
## Footnote
**D**iarrhea
**D**ermatitis symmetrical hyperpigmented rash on sun areas
**D**ementia
**D**EATH
122
Why does Carcinoid Syndrome cause Niacin B3 deficiency?
Carcinoid tumors utilize Tryptophan to secrete tons of Serotonin. Tryptophan is also needed to make Niacin B3. This can --\> Pellagra DDDD
## Footnote
*Do not confuse Carcinoid Syndrome with VIPoma which presents similarly but VI**P**oma affects **P**ancreas while Carcinoid affects small intestine*
123
What role does the adrenal gland play in sepsis physiology?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Explain [stress dose steroids]
normally, stress (sepsis, surgery) ➜ adrenal gland ⇪ endogenous cortisol ➜ [⇪ adrenergic receptor sensitivity to catacholamines] ➜ [⇪ peripheral vasconstriction and ⇪ cardiac contractility] = **MAINTAINS BLOOD PRESSURE DURING STRESS**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
pts chronically immunosuppressed (RA on prednisone) have hypofunction of adrenal glands (from iatrogenic Cushing syndrome) = [relative cortisol deficiency during infection]➜ require exogenous corticosteroid stress dose steroids =
[Hydrocortisone IV 200 mg/day] to prevent/treat septic shock
124
What is [Inferior petrosal sinus sampling] used for?
In patients with elevated ACTH, differentiates source of ACTH ( [Corticotrope Functional Pitutiary Adenoma] vs [Ectopic (SOLC)] )
125
cp Thyroglossal duct cyst
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How should it be managed (2)? why?
[s/p URI, superior to thyroid, fluctuant midline neck mass, in kids that moves superiorly when swallowing]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Thyroid imaging (to ensure native thyroid is functional) ➜ **TDC surgical removal**]
(TDC may be the only site of functioning [ectopic] thyroid tissue so obtain thyroid imaging prior to definitive **surgical** removal)
